1. Is there evidence of spinal cord involvement in this case and, if so, at what level?
No
2. Is there evidence of dorsal or ventral root involvement or spinal nerve involvement in this case, and, if so, what is the level(s) of the involvement?
Possible involvement of the ventral rami of the left C8, T1, and T2 spinal nerves.
The atrophy and slight weakness of the distal muscles of the left upper limb, and the diminished deep tendon reflexes of the triceps (C7, 8) and finger flexors (C8), suggest a lower motor neuron lesion involving these ventral rami. The sensory symptoms and signs suggest involvement of the T1 and T2 (intercostobrachial nerve) ventral rami, including some radicular and neuropathic features.
3. Is there evidence of brachial plexus or peripheral nerve involvement in this case, and, if so, how would you differentiate between the two? What evidence is there to support one or the other site of lesion in this case?
Possible involvement of the inferior trunk of the left brachial plexus (vs the ventral rami as noted in question #2). The signs and symptoms do not adhere to the innervation pattern of any specific peripheral nerve(s).
4. Is there evidence of autonomic nervous system involvement in this case? If so, what signs and symptoms support this conclusion?
Yes. Left ptosis and miosis. Left facial and left upper limb anhidrosis.
5. What is the localizing significance of the left vocal cord paralysis, what nerve was involved in producing that sign, and what was the most likely anatomical location of the pathologic process causing this problem?
This finding is due to involvement of the left recurrent laryngeal nerve, a branch of the vagus nerve (X). The most likely anatomical location of this lesion is close to (and probably posterior to) the aortic arch and left bronchus, or perhaps slightly higher. This would involve the nerve after it “recurs” around the aortic arch (actually the ligamentum arteriosum).
6. What is the localizing significance of the left sided ptosis, miosis, and absence of sweating (anhidrosis), and what specific structures are involved by the pathologic process to produce these signs? This combination of signs and symptoms constitutes a classic neurologic syndrome. What is the name of that syndrome?
Since the left facial anhidrosis involves the entire face, the lesion must involve the sympathetic trunk and/or ganglia proximal to the superior cervical ganglion. Therefore, the lesion involves the preganglionic sympathetic fibers originating in the intermediolateral cell column (lateral horn) of the upper three thoracic spinal cord segments.
In view of the fact that the patient has motor, sensory, reflex, and autonomic signs and symptoms involving the C8, T1, and T2 (intercostobrachial nerve distribution) ventral rami of the spinal nerves (plus or minus the inferior trunk of the brachial plexus), the lesion most likely is located in the posterior aspect of the superior mediastinum (and perhaps the apex of the left lung) and involves the recurrent laryngeal nerve, the upper thoracic sympathetic trunk and its ganglia (including the cervicothoracic ganglion), and the C8-T2 ventral rami of the spinal nerves (vs the inferior trunk of the brachial plexus).
This combination of sympathetic autonomic findings is known as a Horner’s syndrome.
7. In general, what type of pathologic process do you think is involved in this case?
Cancer of the left mainstem bronchus with metastasis or local spread to the posterior aspect of the superior mediastinum, the C7-T2 vertebral bodies, the first three ribs, and perhaps the apex of the lung (Pancoast syndrome).
8. What diagnostic procedure(s) would you undertake at this point?
This case occurred before MRI scanning was available. See Case #2 for a similar, but smaller, lesion
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